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Body Language: N

An Excursion Through the Alphabet in Somatic Terms
by Thomas Myers

In our journey through the alphabet, we have come to the 14th letter, N. The original shape of the letter N, pronounced nun or noon, is a hieroglyph for a snake, sea serpent or eel. Although nun was applied to a cobra (and thus designated royalty, the cobra being part of the Egyptian crown), it specifically referred to a snake in the waters, following the waters that defined the letter M. Thus, N, or nun, is often translated as fish.

In this context, it might be good to remember that the original alphabet from which ours derived is the proto-Sinaitic alphabet, which was developed in the Sinai on the shores of the Red Sea, which is still noted for its good diving - and you still have to watch out for the poisonous sea serpents.

When you look at the sea, a river or even a pool, the moving reflections on the surface often prevent us from seeing what is hidden within. One often imagines the mysterious world concealed beneath the water. This connection between the fish as a hidden benefice, beneath what we can see, is connected with the fish as a symbol of the Piscean age, a 2,000-year period, the end of which we are now living through, as we head into the age of Aries. Jesus, a dominant spiritual figure of this Piscean age, for our culture anyway, is often symbolically associated with fishermen and fish.

Over time and by association, the letter N took a meaning of "that which is hidden in the depths" - as a fish is hidden by the surface distortion. This association led to others, such as the hidden intimate feminine, or the fetus hidden in the amniotic waters of the womb. This generalized eventually to the whole growth of anything living - the oak hidden within the acorn - from the spark of conception to the stretching, pushing and opening as the baby twists its way into this breathing world.

For us, the meaning of the letter N reminds us of our purpose. For our clients, who are often compelled to deal with the hurried surfaces of life, constantly in motion, a visit to a hands-on therapist can be the chance to visit the hidden depths that our nonverbal communication can clarify for them. In bodywork, nothing is added but information, as Deane Juhan consistently reminds us, and the purpose of this added information is to stir the healing powers hidden within a person, and let them flood the body in a restorative way.

NMT in a nutshell
In terms of massage methods, nothing could be more obvious as to what we should explore within the category of the letter N: neuromuscular therapy (NMT). NMT has taken the massage world by storm, putting remedial massage on a more scientific footing with its precise and consistent maps of trigger points and referral zones. Nearly everyone in the trade, and, of course, a great many clients, has experienced the ability of these techniques to reliably diminish pain and improve function.

What was termed neuralgia - shooting pains to other areas when certain tight areas were palpated - first started appearing in medical literature in 1841. Many other words were used to try to describe what remains a puzzling phenomenon - fibromyositis, malign and myofascitis among them. The term "trigger point" first appeared in a 1940 paper by orthopedist A. Steindler, and was the term used by Janet Travell, M.D., in her maiden voyage into the territory in 1952, wherein she added "myofascial" to "trigger point," and talked of myofascial-pain syndrome. Her subsequent work specifically mapped the trigger points and their referral patterns, and her book, Myofascial Pain and Dysfunction: the Trigger Point Manual, which she wrote with David Simons, M.D., and published in 1983, quickly became the bible on the subject of trigger-point mapping and treatment. (The subsequent volume for the lower body was published in 1992.)

Trigger points explained
We now know a good deal more about the etiology and physiology of trigger points, though much remains obscure as well.

Current postulates, correlated with findings, indicate that mechanical strain produces dysfunctional endplate activity at the neuro-motor junction. Excess acetylcholine (ACH), a facilitating neurotransmitter, is released at this myoneural junction, and gets in a positive feedback loop with the calcium released from the strained muscle itself, resulting in high tension and therefore low blood flow (ischemia). With less oxygen and fewer nutrients arriving to the area, the cells cannot run the Krebs cycle to produce adenosine triphosphate (ATP), the basic fuel of cell processes, and remove the calcium ions. Thus both the muscle's and the nerve's gates stay open and the neurotransmitter keeps releasing. This state persists until something - such as a manual intervention - allows enough ATP in to clean up the calcium and ACH and reset the overworked, undernourished area. When the ATP gets back to the area, the trigger point begins to melt.

The funny thing is that in this situation, the physiological trigger point uses very little energy to keep this contracture going. It uses less energy, in fact, than it would to clean up the calcium ions and restore usual functioning, so the contraction continues. This kind of contracture, though, is involuntary, and does not involve motor potentials coming from the spine, which distinguishes it from either a normal voluntary contraction or a spasm, which is involuntary but does involve motor potentials coming down the nerve from the spine. The tension emanating from a trigger point is self-sustaining, without any of these signals from us (our central nervous system, at least) being necessary.

As this contracture goes on, the myosin and actin within the contracture rachet up to their fully shortened (and therefore weak) position, and the local fibers around them are made taut ("locked long," or eccentrically loaded), producing the familiar taut band by which we identify trigger points. These taut bands also load the attachments of the tendons to the periosteum, leading to enthesitis, meaning more trigger points, inflammation or calcium deposition at the attachment site down the fascial line from the neuromuscular trigger point.

Although others had used manual methods on these points before, Travell predominantly used injections of pain medication or cold spray-and-stretch techniques. Raymond Nimmo, D.C., a chiropractor from Granby, Texas, whose research paralleled that of Travell, used receptor tonus technique, similar to the manual methods used today, to release these hypertonic areas.

More pioneers
The NMT method took some time to develop, and thus has a number of pioneers within its story. (Travell and Nimmo are certainly seminal in getting NMT onto the clinical map.)

Paul St. John, a demonstration model at one of Nimmo's seminars, was so impressed with the results on his own problems that he went to massage school in order to be able to explore this healing method for himself. He is responsible in large part for bringing NMT into the world of massage therapists, beginning classes in 1979 that continue to this day.

Judith Walker Delany started studying with St. John in 1983, and was active in organizing his teaching program. In 1989 she separated herself from St. John’s organization to start her own, where she was able to apply her own thoughts on how to best organize adult-learning methods.

Our focus this issue is on Walker Delaney, because her story is one of a dogged pursuit into the hidden depths, below the obvious.

Plumbing the depths
In 1994 Walker Delany embarked on a journey with Leon Chaitow, D.O., on organizing the scientific material around trigger points - doing a literature search and contributing a chapter to his book, Modern NeuroMuscular Techniques. This was her first experience of what is called valid-referenced writing, where you must back up everything you say with research references. It was the wake-up call associated with her delving into the realm that produces the "Aha!" that connects us back to the meaning of the letter N - what is hidden in the depths.

When she first submitted writing to Chaitow’s famous blue pen, her work would come back peppered with marks, saying, “Reference, please." She would write back, "Common knowledge," and he would reply, "Not common knowledge, common belief system–reference please!"

For instance: Effleurage strokes increase lymph drainage from an area. Everybody knows that, right? "Reference, please." Walker Delany went to the books, and lo and behold, she could not find any research to confirm this widely held tenet of massage therapists everywhere. Finally, in an expanded version of The Physician's Guide to Massage Therapy she found a study on the hind leg of a dog, in which lymph movement was increased for 20 minutes after effleurage application. But that's in a dog - any evidence that it also works in a human? Guyton's Medical Textbook of Physiology said light effleurage did increase lymphatic drainage, but deep effleurage would shut down the lymph locally for 24-48 hours, and could even damage the lymph system.

Oops - common knowledge turned out to be a common belief system, and the common belief system turned out to be wrong. How many other untested hypotheses do we have running around like viruses in our brain? Walker Delany believed her teachers (who among us does not?) but found out when she really went to the mat that sometimes two plus two makes 22, not four.

This was a turning point for Walker Delany, and she has spent the time since 1994 searching the books, as well as her own clinical experience, to see if there is something she can really know. To do that, you have to radically set aside your belief systems and be prepared to really look at and accept the evidence. When you do this, sometimes your treasured beliefs are confirmed, and sometimes they are turned upside down.

So now, after years of seeing trigger points as "bad," as pathology (or at least un-adaptive physiology), Walker Delany has turned her own point of view right around. Trigger points, she now believes, are low-energy-consuming contractile devices that can maintain tension within a tissue or general postural adaptation lines in the absence of ATP. These points can maintain the necessary tension for a very long time without too much effort or negative effect, as long as they lie passive, or until they're abused. If you activate them, they'll hurt - such as when the computer jockey lifts his shoulders or when some unusual demand is placed on them.

So, far from being "wrong" or "bad," trigger points are possibly performing marvelously at an efficient, low-energy-consumption job. A trigger point serves a purpose, and before we take it away, we need to understand that purpose. A hamstring trigger point could be serving to help stabilize a hypermobile SI joint, for instance. Take it away manually, and it will simply reform itself, or the body will find an alternative way to stabilize the joint.

"It's really changed my work," says Walker Delany. "I allowed myself to think outside of the 'Trigger points are bad' box. Boxes are great, but stack up the boxes and stand on top of them; don't climb in them and close the lid."

Finding such delicious fish as that idea only occurs in the depths - those reached when you have been considering a piece of work, or a question about that work, for years on end. As a teacher, I find that sometimes people want the deepest secrets of hands-on work right away as they begin, but if you want real insight, there is no substitute for letting your hook lie in those murky waters for a long time. Preferably you will be very quiet, if you want the wiliest and most subtle fish to bite.

This is the message of the letter N - to partake of what is hidden down there, you must take the necessary time to fish in the depths.

Thomas Myers studied directly with Ida Rolf, Ph.D., and Moshe Feldenkrais, Ph.D., and has practiced integrative bodywork for more than 25 years in a variety of cultural and clinical settings. He directs Kinesis Seminars, Inc., which develops and runs international training courses for manual and movement therapists. Myers served as a founding member of the National Certification Board for Therapeutic Massage and Bodywork and as chair of the anatomy faculty at the Rolf Institute. His articles have appeared in numerous magazines and journals, and he is the author of Anatomy Trains - Myofascial Meridians for Manual and Movement Therapists, (Churchill Livingstone, 2001).

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